If one examines the typical surgical appearance of patients who have had facelifts, it becomes easy to analyze the problems and why they result. The best way would be to understand the long-term changes of the vectors of conventional facelifts as shown in Fig. 42.11.
If one judges the vectors of aging of patients in the standing position, they are the same for all humans and are predictable for every person after a certain age (Fig. 42.11a). Without question the conventional facelift can create an excellent jawline but in most cases the tension on the SMAS flap is a shorter, more vertical vector and tension on the upper portion of the conventional flap including the malar fat procedure is less vertical and more superior lateral in spite of claims of vertical "malar fat repositioning." While malar fat techniques and deep plane facelifts have been an improvement over the subcutaneous procedures, the basic problem is still giving an unpredictable result to any patient undergoing conventional techniques. By omitting the surgery of the lower eyelid, the surgeon clearly can promise the patient an early return to social activity often within days. One must remember that a facelift cannot be judged over the first few months since the final results may develop over many months or even several years. With the vectors of the conventional facelift (Fig. 42.11b) there is unopposed tension of the lower face vector. The long upper face vector, however, is more horizontal and is too long to be maintained over the course of time as normal aging proceeds. Thus, the potential progressive relaxation of the orbicularis oculi muscle and cheek and malar fat tends to descend downward in time, creating the "lateral sweep" typically seen with a facelifted person (Fig. 42.11c). If a forehead lift is not done with a conventional rhytidectomy, the forehead also becomes more ptotic in time, creating further disharmony since the patient may eventually have a straight jawline with a very ptotic forehead and looseness of the upper face tissues.
Many patients have a normal crescentric anatomical pattern on the upper cheek area called a malar crescent (Fig. 42.12). The problem with this excessive orbicularis muscle that may become a malar mound or festoon is that it is made even worse with a simple superior lateral facelift, since it is not changed and is in fact made more obvious. While it appears quite normal on a normal unoperated aging face, it becomes a distinct stigma of previous surgery. Of greater significance is the potential for a deeper concavity of the lower eyelid created by orbital indiscriminate lower-eyelid fat (Fig. 42.13). The triad of an unoperated forehead, hollow lower eyelid, and a lateral sweep is pathogenomoic of previous facelift surgery . Frequently, a second facelift is done to correct this stigma of the facelifted appearance but the same lateral vector technique may enforce the undesirable appearance. The effective tightening of the SMAS, which has more longevity than the operated upper facelift tissues in facelift surgery, can create the "pull" of the lower face. Thus, many patients who have undergone two or three facelifts look progressively more distorted in spite of the best attempts by the surgeon to correct the earlier problems. It is for this reason that a composite facelift can be utilized as the best way to reverse the stigmata of previous facelift surgery . While examining a patient with a "facelifted" appearance, superior-medial tension on the patients face with the examiner's fingers will correct this appearance (Fig. 42.11d). This strong tension will counter the tension of the lower face but the flap must include the orbicularis and malar fat to be effective. Because of the need for strong superior medial movement of the face on secondary-facelift patients, the forehead lift must be done otherwise there would be bunching of the tissue in the temporal area after movement of the orbicularis oculi muscle.
izontal lift, continues to fall. Areas typically not addressed by a traditional facelift (red arrows) continue to descend. d The solution. The composite facelift can correct unwanted results by lifting the muscle and fat of the cheek (red arrows) in the correct direction, toward the eye rather than toward the ear, which is the natural youthful position. (Courtesy S. Hamra, Dallas)
Fig. 42.12. Malar crescent. This crescent-shaped fullness corresponds to the lower eyelid muscle (orbicularis muscle) and occurs along the upper cheek area. Because the orbicularis muscle is not addressed in a traditional facelift, it appears more pronounced next to the hollowness created by the traditional lower-eyelid lift and the pull of the traditional facelift. (Courtesy of S. Hamra, Dallas)
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